Nursing Telephone Follow-up to Reduce 30-day Readmissions and Post-discharge Complications for the Adult Hemodialysis Patient

Recurrent hospital readmissions are responsible for considerable health care costs, with readmission rates in patients with end stage renal disease (ESRD) remaining as high as 35.2% within 30 days of discharge (USRDS, 2014). Studies have shown that a considerable percentage of readmissions are preventable through effective discharge planning and patient follow-up after discharge (Mistiaen & Poot, 2006). Providing telephone follow-up (TFU) is a high-quality, low cost method of providing health information, advice, and the recognition of complications early after hospital discharge (Mistiaen & Poot, 2006). This project examined the effectiveness of an evidence-based quality improvement process implemented in an Acute Inpatient Renal Unit providing post-discharge telephone follow-up by experienced dialysis nurses. To enhance the experience of the dialysis patient’s transition from an acute care setting to a home setting, a series of systematic processes were implemented to standardize unit workflow, in addition to utilization and leveraging of the hospital’s electronic medical record (EMR) system to document patient post-discharge progress and outcomes, using a scripted telephone follow up procedure. This quality improvement project compared pre-intervention data to post-intervention data to evaluate the impact on 30-day readmissions and post-discharge complications in a sample of adult hemodialysis (Stage 5 CKD & ESRD) patients. The overall readmission rate decrease by 17% and the 30-day readmission rate decreased by 3.8%. Coordinated and targeted discharge phone follow-up has the potential to benefit this vulnerable patient population.